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THE AGELESS WOMAN RETREAT QUESTIONNAIRE
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On a scale of 1-10 rate your overall physical health.
1
2
3
4
5
6
7
8
9
10
On a scale of 1-10 rate collectively the relationships in your life
1
2
3
4
5
6
7
8
9
10
On a scale of 1-10 rate your anxiety.
1
2
3
4
5
6
7
8
9
10
Is weight management a concern of yours?
Yes
No
How often do you exercise?
Yes
Sometimes
Never
Can you walk a mile without stopping?
Yes
No
Do you meditate?
Yes
Sometimes
Never
I don’t know how
It’s difficult for me
Do you smoke?
Yes
No
Have you been on a women's retreat before?
Yes
No
Do you have any food restrictions? Check all that apply:
Gluten-free
Vegan
Vegetarian
Sugar-free
Nut allergy
None
How often do you drink?
Occasionally
Randomly
Never
Do you snore?
Not at all
Very little
Like a freight train
Will you be bringing a medical device such as a CPAP machine or other?
Yes
No
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